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Dentistry Yañez et al., Dentistry 2014, 4:8

ISSN: 2161-1122 DOI: 10.4172/2161-1122.1000250

Case Report Open Access

Treatment of Anterior Open Bite with the Bimler Functional Appliance: Report
of Three Cases
Ramirez-Yañez GO1*, Mahony D2 and Bimler B3
1Faculty of Dentistry, University of Manitoba, Winnipeg, Canada
2Private Practice, Sydney, Australia
3International Stomatopedic Institute, Wiesbaden, Germany
*Corresponding author: German Ramirez-Yañez, Faculty of Dentistry, University of Manitoba, Winnipeg, Manitoba R3E 0W2, Canada, Tel: 1 289 430 5287; E-mail:
[email protected]
Rec date: Jun 25, 2014, Acc date: Jul 25, 2014, Pub date: Jul 27, 2014
Copyright: © 2014 Ramirez-Yañez GO, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Abstract

There is still controversy regarding the efficacy of functional appliances when treating malocclusion at an early
age. Although a good outcome from treatment is important, the stability of the results over time becomes a major
concern. This paper presents the results of three open bite cases treated with the Bimler type-A appliance in the
mixed dentition. The open bite cases presented here demonstrate stability of the treatment results for more than 14
years without active retention after the active treatment period. A comparison between these cases and those
performed with an elastic functional appliance, and the action of that appliance on tongue posture, are discussed.
The cases presented in this paper support treating malocclusions at an early age with functional appliances. The
features of the appliance chosen to treat an open bite early can be a key factor for the results and stability.

Keywords: Open Bite; Malocclusions; Functional appliances; wear it 24 hours per day, removing it from the mouth when eating.
Treatment stability Treatment stability over 14 years or more is presented and discussed.

Introduction
The treatment of anterior open bite is a great challenge in
orthodontics. A controversy exists about the ideal developmental stage
at which an open bite should be treated. Some authors recommend
starting treatment in the early mixed dentition with either fixed or
removable functional appliances [1-3], while others endorse waiting
and treating later in the permanent dentition [4-6].
The high incidence of relapse, even in those cases where treatment
involves surgery, is one of the major concerns when treating open bites
[7,8]. Tongue thrust is associated with this kind of malocclusion and
has been reported as one of the major causes of relapse [9]. Although
some reports tend to discourage the use of functional appliances
[6,10], treatments with functional techniques have been reported to
produce beneficial skeletal outcomes. Functional appliances can
stimulate a counterclockwise mandibular rotation, permit the
mandible to continue growing in a more favorable direction and
encourage a physiological posture of the tongue during oral functions
[2,3,11-14]. In that context, early correction of open bites with Figure 1: Picture showing the Bimler Type A appliance with is
functional appliances can lead to favorable and stable results components: (a) acrylic plates; (b) coffin spring; (c) lower shield;
[13-15,16-19]. However, the results of treatment may depend on the (d) buccal bow; and, (e) dorsal arches
features of the functional appliance, which must be designed to deal
with the mandibular rotation, to improve muscular activity and to
correct tongue thrust [11,12,14]. Cases Report
This paper reports the clinical and cephalometric modifications
produced in three open bite patients treated with a functional Cephalometric measurements
appliance, the Bimler type-A (Figure 1). This appliance was proposed
by Prof. Hans Peter Bimler in Germany, by the middle of the last Cephalometric measurements before and after treatment were
century. All three cases were treated with the Bimler appliance only, obtained as follows: Sella-Nasion-Point A (SNA), Sella-Nasion-Point B
delivering a new one every 6-8 months, and patients were instructed to (SNB), Point A-Nasion-Point B (ANB), Gonion-Gnathion/Sella-

Dentistry Volume 4 • Issue 8 • 1000250

ISSN:2161-1122 Dentistry, an open access journal
Citation: Ramirez-Yañez GO, Mahony D, Bimler B (2014) Treatment of Anterior Open Bite with the Bimler Functional Appliance: Report of Three
Cases. Dentistry 4: 250. doi:10.4172/2161-1122.1000250

Page 2 of 6

Nasion (GoGn/SN), Anterior Nasal Spine-Posterior Nasal Spine/Sella- Superior (GoS) and Gonion Inferior (GoI) angles. Values for the
Nasion (ANS-PNS/SN), ANS-PNS/Pterigoid Line (ANS-PNS/Pt), and, measured angles are presented in Table 1.
Gonion angle, subdivided as described by Jarabak into Gonion

Case 1 Case 2 Case 3

Before After Diff. Before After Diff. Before After Diff.

SNA 82 83 1 82 82 0 81.5 81 -0.5

SNB 77 81 4 76 77 1 77 76 -1

ANB 5 2 -3 6 5 -1 5 5 0

GoGn/SN 31 25 -6 38 36 -2 44 41 -3

Maxilla/SN 5 7 2 8 13 5 11 13 2

Upper Gonial 55 55 0 59 55 -4 51 58 7

Lower Gonial 70 68 -2 75 71 -4 80 80 0

Gonial Angle 125 123 -2 134 126 -8 131 138 7

Maxilla/Pt 87 85 -2 93 88 -5 87.5 86 -1.5

Table 1: Values of the measured cephalometric angles of the three clinical cases presented in this report

Case 1 close the open bite, improve the sagittal position of the mandible and
encourage a physiological position of the tongue at rest and
swallowing, with the tip of the tongue postured on the incisive papillae
region. This treatment plan involved the Bimler type-A appliance only.
After 36 months of treatment, the patient presented with the
mandible postured forward and the open bite closed (Figure 2b).
Tongue thrust was corrected and the tongue was resting in a
physiological position. Teeth were aligned and the dental overbite and
overjet were within normal values. Cephalometrics at that point
revealed an increase of SNB of four degrees with a consequent
reduction of ANB of three degrees. SNA was not modified by the
treatment. Go-Gn/SN reduced six degrees, which was interpreted as a
counterclockwise mandibular rotation. Concurrently, a slight rotation
of the mandibular body was shown as the GoI angle reduced two
degrees. ANS-PNS/SN increased two degrees, confirming the maxilla
rotated downward. Since the objectives of treatment were achieved at
that point, the appliance was discontinued. The patient was followed
up over a 14 year period, with the overbite and overjet showing no
variation and the tooth alignment maintained (Figure 2c).
Figure 2: The figure shows the photos of case 1 when the patient
was (a) eight years old; (b) eleven years old; and, (c) twenty-five
years old. It also shows the drawings from the cephs before and Case 2
after treatment (a&b). Notice the stability of the results after 14 A nine year old girl presented with an open bite (3 mm negative
years without any post-treatment retention overbite) and normal overjet. Clinical examination revealed a Class I
canine relationship, under-erupted mandibular incisors and tongue
thrust (Figure 3a). Cephalometrics exposed a reduced angle between
An eight year old girl presented for orthodontic treatment the cranial base and the maxilla (ANS-PNS/SN) and an increased
complaining she cannot touch her front teeth when closing her mouth. Gonial angle. Sagittal maxillo-mandibular relationship was within
The clinical exam revealed a 3 mm negative overbite, 3.5 mm overjet normal values. The Upper Gonial angle was increased, indicating a
and a Class II canine relationship (Figure 2a). Cephalometric measures posterior rotation of the mandibular ramus. The Lower Gonial angle
showed a slight counterclockwise rotation of the maxilla, while the value was within the normal parameters. The case was diagnosed as a
Gonial angle was within normal values. The mandible was retruded Class I malocclusion associated with a combined skeletal and dental
and the maxilla was in a normal relationship with the cranial base. open bite, due to mouth breathing and tongue thrust. Treatment was
Tongue thrust was observed on swallowing. The case was diagnosed as planned with the Bimler type-A appliance. The objectives of the
a skeletal Class II malocclusion with an open bite of dental origin, treatment were to close the open bite without affecting the sagittal
associated with tongue thrust. The objectives of treatment were to

Dentistry Volume 4 • Issue 8 • 1000250

ISSN:2161-1122 Dentistry, an open access journal
Citation: Ramirez-Yañez GO, Mahony D, Bimler B (2014) Treatment of Anterior Open Bite with the Bimler Functional Appliance: Report of Three
Cases. Dentistry 4: 250. doi:10.4172/2161-1122.1000250

Page 3 of 6

maxillo-mandibular relationship. Treatment also aimed to promote the incisors into the correct position. The prognosis in this case was
physiological tongue position at rest and swallowing. guarded since a serial extraction protocol had been initiated on the
upper dental arch by the previous dentist with extraction of the first
premolars.

Figure 3: The figure shows the photos of case 2 when the patient
was (a) nine years old; (b) eleven years old; and, (c) twenty-nine
years old. It also shows the drawings from the cephs before and Figure 4: The figure shows the photos of case 3 when the patient
after treatment (a&b). Notice the stability of the results after 18 was (a) eight years old; (b) thirteen years old; and, (c) twenty-nine
years without using any retention years old. It also shows the drawings from the cephs before and
after treatment (a&b). Notice the stability of the results after 16
years follow up with no retention
After two years of treatment, the objectives were attained and active
treatment was stopped. Clinically the open bite was closed and the
mandibular incisors leveled with the posterior teeth (Figure 3b). Active treatment with the functional appliance ended when the
Cephalometric measurements revealed that Upper and Lower Gonial patient was 12 years old, totaling four years of active treatment (Figure
angles reduced four degrees each, with no modifications in the SNA, 4b). Clinically, the open bite was closed and the overjet and overbite
SNB or ANB angles. The maxilla rotated downward as the ANS- were within normal values. No skeletal sagittal changes were
PNS/SN angle increased five degrees correlating with a similar measurable at the end of treatment. Nevertheless, cephalometry
reduction in the ANS-PNS/Pt angle. Those measurements suggest an computed an improvement in the GoGn/SN angle, which reduced
upward rotation of the mandible, particularly of the mandibular body, three degrees. The ANS-PNS/Pt angle reduced one and a half degrees.
accompanied by a downward rotation of the maxilla. In this case, Although those latter values suggested the mandibular body tended to
treatment improved the vertical relationship between maxilla and rotate into a counterclockwise direction and the maxilla into a
mandible without affecting their sagittal relationship. The patient did clockwise direction, an increase of seven degrees in the Gonial angle
not wear a retainer after the active treatment. Eighteen years of follow inferred a continued vertical growth pattern. Regardless of the adverse
up showed no relapse of the open bite or tooth misalignment (Figure cephalometric results in the Gonial angle, the clinical results
3c). accounted for a successful treatment of the open bite.
The patient discontinued using the functional appliance at that
Case 3 point. Fixed orthodontic treatment was suggested to de-rotate the
An Eight year old girl was referred for treatment because an upper right second premolar (Figure 4c), but,the patient was happy
anterior open bite. The clinical exam revealed a 3 mm overbite and an with the results and did not consider having brackets for that minor
edge-to-edge relationship at the incisors. The canine’s relationship was adjustment. No retention device was worn afterwards. A sixteen year
Class III on the right and Class I on the left. Mandibular incisors were follow up showed no relapse of the open bite. The rotated upper
under-erupted. (Figure 4a) Cephalometric measurements exposed a premolar stayed in the same position over the follow up period.
tendency to skeletal Class II malocclusion as the SNB angle was
reduced and the ANB angle was slightly increased. The Gonial and the Discussion
Go-Gn/SN angles were increased indicating a clockwise rotation of the
A controversy still exists regarding the efficacy and long-term
mandibular corpus. The ANS-PNS/Pt angle was reduced, suggesting
stability of functional appliances when treating malocclusions. Three
the maxilla rotated downward. The case was diagnosed as a Class II
cases presented here have shown that the Bimler type-A is an
skeletal malocclusion associated with a combined skeletal and dental
alternative for treating sagittal and vertical deviations of the dental
open bite due to tongue thrust.
occlusion. Furthermore, these clinical cases showed stable clinical
As with the two previous cases, this patient was treated only with results after a period of 14 years or more.
the Bimler Type A appliance. The objectives of the treatment were to
A remarkable finding is that the Bimler type-A appliance stimulated
close the open bite and improve the overjet and overbite by means of
a favorable rotation of the mandible. That effect was quantified as
positioning the mandible slightly forward and guiding the eruption of

Dentistry Volume 4 • Issue 8 • 1000250

ISSN:2161-1122 Dentistry, an open access journal
Citation: Ramirez-Yañez GO, Mahony D, Bimler B (2014) Treatment of Anterior Open Bite with the Bimler Functional Appliance: Report of Three
Cases. Dentistry 4: 250. doi:10.4172/2161-1122.1000250

Page 4 of 6

there was a reduction in the values of the GoGN/SN and the Inferior position of the tongue between the incisors teeth before treatment can
Gonial angles caused by the treatment in two of the three cases be controlled. That would explain the counter-clockwise mandibular
presented here. In open bite patients, the tongue at rest tends to be rotation observed in the first two clinical cases presented here. That
positioned between the upper and lower incisors and thrusting favorable rotation of the mandible in open bite cases has also been
forward on swallowing (Figure 5a) [9]. These patients had tongue reported with other functional appliances, such as the Frankel’s
thrust which was not present at the end of the active treatment with Functional Regulator [20,21]. Randomized clinical studies with
the functional appliance. That positive outcome could have resulted functional appliances evaluating tongue posture with ultrasound or
from a change in the posture of the tongue at rest and swallowing cinefluorography are required to test this hypothesis.
stimulated by the functional appliance [17].
Myofunctional therapy has shown to improve the results when
combined with orthodontics [22,23]. As reported here, the causes of
the open bite in the three cases were tongue thrust and mouth
breathing. In situations like that, myofunctional therapy could be
considered beside the functional treatment to improve the stability of
the treatment and reduced the time required to treat the malocclusion.
Case three was more complicated and the prognosis was guarded as
it was a skeletal open bite associated with an increased value for the
Gonial angle. Plus, the two first premolars were already extracted
when the patient was accepted for treatment. Regardless of those
adverse issues, clinical success was achieved and no relapse was
observed during the follow up period of 16 years. An interesting point
in this case was that the clockwise mandibular rotation continued
during the treatment period. The Gonial angle’s value was higher at
the end of the active treatment. In that context, the dolichofacial
Figure 5: (A) Diagram representing the position of the tongue and morphological pattern was maintained. A recent study reported that
the hyperactivity of the muscles attaching the tongue and the the morphological facial pattern may be maintained after mouth
mandible to the hyoid bone in open bite. A situation like that breathing rehabilitation, even though mandibular structural changes
favours a clock-wise rotation of the mandible. (B) Diagram are produced [24]. The results of our last case agree with that study.
representing the relaxation of the muscles attaching the tongue and The authors suggest that that physiological positioning of the tongue
mandible to the hyoid bone when the tip of the tongue is placed on achieved at the end of the active treatment helped to prevent relapse
the incisive papilla region. This change in the position of the tongue regardless of the craniofacial growing pattern. In that context, the
favours a counter clock-wise rotation of the mandible influence of the soft tissues on mandibular development should be
considered critical for the stability of the results after treatment [25].
Treatment efficiency and stability are two of the issues highly
In order to explain how the Bimler type A can stimulate mandibular discussed regarding functional appliances. Systematic reviews and
rotation by bringing the tongue to a more physiological position, it is meta-analysis evaluating the efficiency of functional appliances to treat
necessary to understand how the tongue, the supra-hyoid muscles and malocclusions do not show the reality of the results frequently
the mandible work together. Thus, based on the anatomy of the observed by the clinicians, who in many cases get similar results to
tongue, a hypothesis on the effects of the functional appliance from those presented here. Most of the clinical studies reported in the
tongue position and function is presented literature have been performed with rigid and bulky functional
One of the major muscles of the tongue, the hyoglossus muscle, appliances (eg. Bionator, Monoblock, Twin-block, etc.). Those rigid
attaches to the hyoid bone, which also serves as insertion for the appliances are used to improve the sagittal posture of the mandible.
anterior digastric and the geniohyoid muscles. The latter two muscles They maintain the mandible in a forwarded position, and thus, they
simultaneously attach to the posterior-inferior border of the produce a splint effect. Although the Bimler appliance similarly moves
mandibular symphysis (Figure 5). When the tongue’s tip is positioned the mandible forward, it has less acrylic with most of its structure
between the maxillary and mandibular incisors teeth, the dorsum of being built with wires. That feature converts the Bimler into a more
the tongue is moved upward and forward. That pulls the hyoid bone elastic appliance, modifying the posture of the mandible in a sagittal
upward and backward because the hyoglossus muscle has to contract direction and giving some degree of freedom for vertical rotation [26].
(Figure 5a). A backward position of the hyoid bone stretches the That freedom given to the mandible permits the counter-clockwise
anterior digastrics and the geniohyoid muscles pulling the mandibular rotation by stimulating a better tongue position. Therefore, a stimulus
symphysis down and backward. That stimulates the mandibular body on the masticatory muscles making them able to maintain the
to rotate in a clockwise direction (Figure 5a). mandible in a new sagittal relationship and the counter-clockwise
mandibular rotation observed accounted for the successful result in
The functional appliance can counteract that negative effect by two of the three cases presented here.
positioning the tip of the tongue on the incisive papilla, permitting the
dorsum of the tongue to displace backward, relaxing the hyoglossus Another matter which needs to be viewed is the search for
muscle and reducing the traction on the hyoid bone. In such a mandibular growth. When the efficacy of functional appliances has
situation, the hyoid bone is allowed to reach a more physiological been evaluated by different authors, most of the studies look for
position (Figure 5b), reducing the down and backward pulling exerted mandibular growth. Changing the posture of the mandible requires a
on the mandibular symphisis by the anterior digastric and geniohyoid sequence of cellular events targeting increased bone formation, and as
muscles. In this way, the effects produced by the non-physiological a result, mandibular growth [27,28]. That concept has probably misled

Dentistry Volume 4 • Issue 8 • 1000250

ISSN:2161-1122 Dentistry, an open access journal
Citation: Ramirez-Yañez GO, Mahony D, Bimler B (2014) Treatment of Anterior Open Bite with the Bimler Functional Appliance: Report of Three
Cases. Dentistry 4: 250. doi:10.4172/2161-1122.1000250

Page 5 of 6

the dental community, who expect mandibular growth to be a result of anterior open bite malocclusion. Am J Orthod Dentofacial Orthop 108:
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Citation: Ramirez-Yañez GO, Mahony D, Bimler B (2014) Treatment of Anterior Open Bite with the Bimler Functional Appliance: Report of Three
Cases. Dentistry 4: 250. doi:10.4172/2161-1122.1000250

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